Quality Improvement Project: Discharge Opioid Prescribing Guideline for the Urologic Surgery Patient Population

Christopher Acebedo, DNP, ACNP-BC, CCRN; Nancy Hung, PharmD; Cameron Heshmati

Disclosures

Urol Nurs. 2020;40(1):23-30. 

In This Article

Abstract and Introduction

Abstract

Among the urologic surgery patient population, the conventional opioid prescribing practice is arbitrary, provider preferential, and not data-driven. This practice increases the risk of over-prescription, chronic opioid use, and surplus of opioid analgesics. To address this problem, a discharge opioid prescribing guideline was developed, implemented, and evaluated as a quality improvement project. guideline implementation significantly decreased opioids prescribed at discharge. There was a significant increase in opioid refills, despite the favorable self-reported pain control, absence of readmission due to acute pain episode, and greater than 80% of patients reporting opioid surplus 5 days after discharge. This quality improvement project demonstrated that a discharge opioid prescribing guideline effectively decreased opioid prescribing.

Introduction

The Centers for Disease Control and Prevention (CDC) (2018) estimated that 130 opioid-related deaths occur in the United States each day. Recent data suggest there was a 9.6% increase in overdose deaths in the United States from 2016 to 2017; 68% were attributed to opioid use (CDC, 2019). The estimated economic burden of opioid overdose, abuse, and dependence is as high as 78.5 billion dollars (Florence et al., 2016). This epidemic may be attributed, at least in part, to over-reliance and lenient opioid prescribing practices. Strategies to address this opioid crisis are needed at both macrosystem and microsystem levels.

Studies have shown that opioid overprescription is prevalent among specialty surgery patient populations. For example, in a study of 61 postoperative patients in Colorado, 83% of patients who underwent Caesarian section needed only half of the prescribed opioid quantity after discharge, while 45% of patients who underwent thoracic surgery required none (Bartels et al., 2016). Similarly, among 3,412 patients who underwent elective surgical procedures, almost 53% of patients consumed less than half of the opioids prescribed at discharge, and 77% of patients discharged with an opioid had an opioid surplus at home (Thiels et al., 2018). Among the urologic surgery patient population, findings are equally alarming (Bates et al., 2011; Fujii et al., 2018).

Population and procedure-specific prescribing guidelines and protocols have decreased over-prescription of opioids across a variety of settings (Chen et al., 2016; del Portal et al., 2016; Large et al., 2018; Tong et al., 2018). For example, in a study done by del Portal and colleagues (2016), implementation of prescribing guideline in the emergency department significantly decreased opioid prescribing. Studies have also demonstrated that a multimodal approach is an essential element of a prescribing guideline (Large et al., 2018; Tong et al., 2018; Wick et al., 2017; Xu et al., 2015) and that tailoring the pain regimen based on the procedure performed appears to adequately control postoperative pain after discharge while mitigating the potential for over-prescription among the specialty surgery patient population (Hill et al., 2017; Khater et al., 2017; Large et al., 2018; Scully et al., 2018; Tong et al., 2018; Xu et al., 2015). In addition, guidelines that incorporate the use of a state-wide prescription drug monitoring program (PDMP) are effective in decreasing over-prescription (Bao et al., 2016). PDMPs are state-administered programs that monitor and collect data on prescribing and dispensing controlled substances. These programs may be accessed electronically by authorized providers to guide opioid prescribing in the clinical setting.

Conventional practice in a high patient volume urologic surgery service is to prescribe opioids at a traditionally accepted quantity without incorporating the expected procedure-specific pain burden. Such practice likely results in over-prescription and a surplus of opioid agents at home that can potentially increase misuse and abuse in the community. The goal of this quality improvement (QI) project was to decrease opioid prescription at discharge, while providing safe and adequate postoperative pain control among patients who underwent urologic surgery in a single acute care center by implementing a discharge opioid-prescribing guideline. Outcome measures were the amount of opioids prescribed at discharge and the adequacy of the post-discharge pain control.

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